PrepU - Chapter 44: Digestive and Gastrointestinal Treatment Modalities

As part of the process of checking the placement of a nasogastric tube, the nurse checks the pH of the aspirate. Which pH finding would indicate to the nurse that the tube is in the stomach?

4

A nurse is caring for a patient with a Salem sump gastric tube attached to low intermittent suction for decompression. The patient asks, "What's this blue part of the tube for?" Which response by the nurse would be most appropriate?

"It is a vent that prevents backflow of the secretions."

A client has a nasogastric tube for continuous tube feeding. The nurse does all the following every shift to verify placement (select all options that apply):

- Compares exposed tube length with original measurement - Visually assesses the color of the aspirate - Checks the pH of the gastric contents

A nurse is caring for a client receiving parenteral nutrition at home. The client was discharged from the acute care facility 4 days ago. What would the nurse include in the client's plan of care? Select all that apply.

- Daily weights - Intake and output monitoring - Calorie counts for oral nutrients

A nurse is assessing a client receiving tube feedings and suspects dumping syndrome. What would lead the nurse to suspect this? Select all that apply.

- Diaphoresis - Diarrhea - Tachycardia

Semi-Fowler position is maintained for at least which timeframe following completion of an intermittent tube feeding?

1 hour

A patient has a gastric sump tube inserted and attached to low intermittent suction. The physician has ordered the tube to be irrigated with 30 mL of normal saline every 6 hours. When reviewing the patient's intake and output record for the past 24 hours, the nurse would expect to note that the patient received how much fluid with the irrigation?

120

The client has the intake and output shown in the accompanying chart for an 8-hour shift. What is the positive fluid balance?

260

A patient has a gastric sump tube attached to low intermittent suction. The nurse empties the suction collection chamber and records an output of 320 mL for this 8-hour shift. The record shows that the tube had been irrigated with 20 mL of normal saline twice this shift. What would be the actual output of the gastric sump tube?

280

A patient is receiving continuous tube feedings via a small bore feeding tube. The nurse irrigates the tube after administering medication to maintain patency. Which size syringe would the nurse use?

30-mL

A client has been prescribed a protein intake of 0.6 g/kg of body weight. The client weighs 154 pounds. The nurse calculates the daily protein intake to be how many grams? Enter the correct number ONLY.

42

The nurse inserts a nasogastric tube into the right nares of a patient. When testing the tube aspirate for pH to confirm placement, what does the nurse anticipate the pH will be if placement is in the lungs?

6

A patient is receiving a continuous tube feeding. The nurse notes that the feeding tube was last irrigated at 2 p.m. The nurse would plan to irrigate the tube again at which time?

6 p.m. to 8 p.m.

The nurse is caring for a patient who has dumping syndrome from high-carbohydrate foods being administered over a period of fewer than 20 minutes. What is a nursing measure to prevent or minimize the dumping syndrome?

Administer the feeding with the patient in semi-Fowler's position to decrease the effect of gravity on transit time.

A client is recovering from percutaneous endoscopic gastrostomy (PEG) tube placement. The nurse

Administers an initial bolus of 50 mL water

A client is receiving a parenteral nutrition admixture that contains carbohydrates, electrolytes, vitamins, trace minerals, and sterile water and is now scheduled to receive an intravenous fat emulsion (Intralipid). What is the best action by the nurse?

Attaches the fat emulsion tubing to a Y connector close to the infusion site

A nonresponsive client has a nasogastric tube to low intermittent suction due to gastrointestinal bleeding. It is most important for the nurse to

Auscultate lung sounds every 4 hours.

The primary source of microorganisms for catheter-related infections are the skin and which of the following?

Catheter hub

If a client's central venous catheter accidentally becomes disconnected, what should a nurse do first?

Clamp the catheter.

A nurse is caring for a client with a long-term central venous catheter. Which care principle is correct?

Clean the port with an alcohol pad before administering I.V. fluid through the catheter.

A nurse providing care to a patient who is receiving nasogastric tube feedings finds that the tube is clogged. Which of the following is no longer considered appropriate to use to unclog the tube?

Cranberry juice

The nurse is to administer a cyclic feeding through a gastric tube. It is most important for the nurse to

Elevate the head of the bed to 45 degrees.

A patient is receiving nasogastric tube feedings. The intake and output record for the past 24 hours reveals an intake of 3100 mL and an output of 2400 mL. The nurse identifies which nursing diagnosis as most likely?

Excess fluid volume

A client has been receiving intermittent tube feedings for several days at home. The nurse notes the findings as shown in the accompanying documentation. The nurse reports the following as an adverse reaction to the tube feeding:

Fasting blood glucose level

The nurse is to discontinue a nasogastric tube that had been used for decompression. What is the first action the nurse should take?

Flush with 10 mL of water.

Gastrostomy feedings are preferred to nasogastric feedings in the comatose patient, because the:

Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration.

The nurse is caring for a comatose patient and administering gastrostomy feedings. What does the nurse understand is the reason that gastrostomy feedings are preferred to nasogastric (NG) feedings in the comatose patient?

Gastroesophageal sphincter is intact, lessening the possibility of regurgitation.

A client has a gastrointestinal tube that enters the stomach through a surgically created opening in the abdominal wall. The nurse documents this as which of the following?

Gastrostomy tube

Residual content is checked before each intermittent tube feeding. The patient would be reassessed if the residual, on two occasions, was:

Greater than 200 mL.

A patient is receiving parenteral nutrition. The current solution is nearing completion, and a new solution is to be hung, but it has not arrived from the pharmacy. Which action by the nurse would be most appropriate?

Hang a solution of dextrose 10% and water until the new solution is available.

The nurse is managing a gastric (Salem) sump tube for a patient who has an intestinal obstruction and will be going to surgery. What interventions should the nurse perform to make sure the tube is functioning properly?

Keep the vent lumen above the patient's waist to prevent gastric content reflux.

When assisting with the plan of care for a client receiving tube feedings, which of the following would the nurse include to reduce the client's risk for aspiration?

Keeping the client in a semi-Fowler's position at all times.

The health care provider orders the insertion of a single lumen nasogastric tube. When gathering the equipment for the insertion, what will the nurse select?

Levin tube

A client is receiving parenteral nutrition (PN) through a peripherally inserted central catheter (PICC) and will be discharged home with PN. The home health nurse evaluates the home setting and would make a recommendation when noticing which circumstance?

No land line; cell phone available and taken by family member during working hours

A client recovering from gastric bypass surgery accidentally removes the nasogastric tube. What is the best action by the nurse?

Notify the surgeon about the tube's removal.

The nurse is caring for a client who has a gastrostomy tube feeding. Upon initiating care, the nurse aspirates the gastrotomy tube for gastric residual volume (GRV) and obtains 200 mL of gastric contents. What is the priority action by the nurse?

Place the client in a semi-Fowler's position with the head of the bed at 45 degrees.

When a central venous catheter dressing becomes moist or loose, what should a nurse do first?

Remove the dressing, clean the site, and apply a new dressing.

The nurse is inserting a Levin tube for a patient for gastric decompression. The tube should be inserted to 6 to 10 cm beyond what length?

The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process

The nurse is inserting a nasogastric tube and the patient begins coughing and is unable to speak. What does the nurse suspect has occurred?

The nurse has inadvertently inserted the tube into the trachea.

A positive nitrogen balance indicates which condition?

Tissue growth

After teaching nursing students about methods to assess gastric tube placement, the instructor determines that the teaching was successful when the group identifies which of the following as the most accurate method?

X-ray visualization

To ensure patency of central venous line ports, diluted heparin flushes are used

daily when not in use.

A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, what must the nurse remain alert for?

diaphoresis, vomiting, and diarrhea.

Rebound hypoglycemia is a complication of parenteral nutrition caused by

feedings stopped too abruptly.

Which condition is caused by improper catheter placement and inadvertent puncture of the pleura?

pneumothorax

The client is on a continuous tube feeding. The nurse determines the tube placement should be checked every

shift

The most significant complication related to continuous tube feedings is

the increased potential for aspiration.

The nurse confirms placement of a client's nasogastric (NG) tube using a combination of visual and pH assessment of the aspirate. The nurse determines that the NG tube remains properly placed when the pH of the aspirate is

acidic

The primary source of microorganisms for catheter-related infections are the skin and the

catheter hub.

When assessing whether a client is a candidate for home parenteral nutrition, what would be important to address? Select all that apply.

- Family support - Telephone access - Motivation for learning - Health status

A nursing instructor is preparing a class about gastrointestinal intubation. Which of the following would the instructor include as reason for this procedure? Select all that apply.

- Remove gas and fluids from the stomach - Diagnose gastrointestinal motility disorders - Flush ingested toxins from the stomach - Administer nutritional substances